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Keywordsdisaster managementemergency preparednessperinatal nursing

Perinatal Considerations in the HospitalDisaster Management ProcessSusan Orlando, Denise Danna, Gloria Giarratano, Robbie Prepas, and Cheri Barker Johnson

ABSTRACT

Nurses play a vital role in providing care to mothers and infants during a disaster, yet few are fully prepared for the

challenges they will encounter under extreme conditions. The ability to provide the best possible care for families

begins with understanding the perinatal issues in relation to each phase of the disaster management process. This

article reviews the hospital and perinatal nursing role in the mitigation, preparedness, response, and recovery phases

of disaster management.

JOGNN, 39, 468-479; 2010. DOI: 10.1111/j.1552-6909.2010.01158.x

Accepted March 2010

Hospital emergency preparedness remains at

the forefront of disaster planning after the cat-

astrophic events that marked the past decade. On

September 11, 2001, the terrorist attacks on the

World Trade Center and the Pentagon demon-

strated the important role hospitals play in the

frontline response to sudden, unexpected inci-

dents. Saint Vincent’s Hospital in Manhattan (New

York) and Virginia Hospital Center-Arlington

activated their emergency operations, becoming vi-

tal elements of the organized medical response

(Jurkovich, 2003; Kirschenbaum, Keene, O’Neil,

Westfal, & Astiz, 2005). The subsequent anthrax at-

tacks in 2002 demonstrated the need for hospital

personnel to know how to safely respond to victims

of bioterrorism while maintaining a secure environ-

ment for other patients and sta¡. Likewise, the

events following the 2005 Hurricanes Katrina and

Rita exposed the necessity of a resilient hospital

infrastructure with the sustainability to care for vul-

nerable populations days following a widespread

community disaster.

Among the most vulnerable populations in the af-

termath the 2005 hurricanes were pregnant

women and newborns. The unexpected levee sys-

tem failure in New Orleans following the passage of

Hurricane Katrina required that mothers and new-

borns be sustained in deteriorating conditions

without back-up power, limited food and water,

and sometimes insecure settings (Giarratano, Or-

lando, & Savage, 2008). Through the heroic e¡orts

of many, all mothers and newborns were eventually

rescued and survived. Yet the evacuation process

was riddled with complications and took more than

4 days to fully accomplish (Orlando, Bernard, &

Mathews, 2008). Meanwhile, the surge in mother/

newborn services in receiving hospitals, such as

Woman’s Hospital in Baton Rouge 70 miles north-

west of New Orleans, was enormous as they

received and stabilized more than 122 infants and

high-risk obstetric patients (Spedale, 2006).

These events sparked renewed attention to disaster

planning in mother/newborn hospital settings, mo-

tivating work that resulted in the 2007 National

Working Group for Women and Infant’s Needs

in Emergencies in the United States (Women

and Infants Service Package, 2007) and the State

Emergency Planning and Preparedness Recom-

mendations for Maternal and Child Populations in

2008 (Association of Maternal and Child Health

Programs) that guide disaster management in

acute care and community settings. In addition, a

plethora of information on disaster planning

from governmental agencies such as the Centers

of Disease Control and Prevention (CDC) and De-

partment of Health and Human Services (DHHS)

and varied health care organizations provides

a foundation for developing guidelines aimed at

Susan Orlando, DNS,APRN, NNP-BC, is anassistant clinical professorand program director of theNeonatal Nurse PractitionerTrack in the School ofNursing, Louisiana StateUniversity Health SciencesCenter, New Orleans, LA.

CorrespondenceSusan Orlando, DNS,APRN, NNP-BC, LouisianaState University HealthSciences Center, School ofNursing, 1900 GravierStreet, New Orleans, LA70112.sorlan@lsuhsc.edu

The authors and plannersfor this activity report noconflict of interest orrelevant financialrelationships. The articleincludes no discussion ofoff-label drug or devise use.No commercial support wasreceived for this educationalactivity.

(Continued)

JOGNN I N F O C U S

468 & 2010 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses http//jognn.awhonn.org

minimizing the impact of disaster or pandemics on

women and mother/newborn patients.

Whether caused by natural forces, technological fail-

ures, or intentional violence, disasters are destructive

events that result in property damage, mass casual-

ties, injuries, or illness that can overwhelm the

community and the health care system. Pregnant

women and newborns are most a¡ected by environ-

mental and social changes in the community with

the disruption of housing, routine medical care, the

food and water supply and increased exposure to vi-

olence or toxins (Pfei¡er et al., 2008). Pregnancyand

childbirth place women at higher risk for health

complications from disasters including obstetrical

complications, such as low birth weight and preterm

birth (Xiong et al., 2008).

The purpose of this article is to review the basic

phases of emergency management that include

mitigation, preparedness, response, and recovery

in relation to managing the special needs of hospi-

talized women and newborns in situations of

emergencies or disasters. Additionally, governmen-

tal and organizational policies with recommen-

dations or guidelines that regulate hospital and

community disaster preparation are described.

Governmental, Regulatory, andOrganizational Influences onHospital Disaster PreparationFederal, state, and local governments have de¢ned

roles and responsibilities in working with nongov-

ernment organizations and the private sector to

implement a shared and coordinated approach

to disaster management in the United States. The

National Response Framework (NRF) provides

guidance to all levels of government in operational

planning to prepare and respond to disasters (U.S.

Department of Homeland Security [DHS], 2008).

Each disaster response is carefully evaluated to

identify areas needing improvement. The NRF is

based on action plans incorporating key disaster

response principles and replaces the National Re-

sponse Plan (NRP) (DHS, 2004).

Although state and local governments handle most

emergency events, federal resources may be de-

ployed in advance of an impending disaster. When

local and state resources are overwhelmed, the

governor can request assistance from the federal

government through the Department of Homeland

Security. Local governments rely on state resources

such as emergency management, police, transpor-

tation, health agencies, and the National Guard.

The NRF provides a master plan for predisaster col-

laboration among local government, nongo-

vernment, and private agencies (DHS, 2008).

Hospitals represent only one stakeholder at the local

level within the overall health care system needed for

disaster preparedness. Pharmacies, home care ser-

vices, health centers, public health departments,

and the overall community must integrate their ef-

forts to build community-wide and regional

networks that can respond in a coordinated manner

(Knebel & Phillips, 2009). Figure 1 outlines the orga-

nizational chart for disaster management.

There have been a number of recent Congressional

acts aimed at supporting state and local coordina-

tion e¡orts among all stakeholders. The passage of

the Public Health Security and Bioterrorism Pre-

paredness and Response Act in 2002 provided

funding and guidance to improve local and state

hospital preparedness for public health emergen-

cies. This was followed in 2006 with the Pandemic

and All-Hazards Preparedness Act (PAHPA). This

act set up the Department of Health and Human

Services (DHHS) as the lead agency for coordinat-

ing public health and medical emergencies and an

assistant secretary for preparedness and response

(ASPR) to oversee the Hospital Preparedness Pro-

gram (HPP). The HPP funding is administrated

through state health departments to promote com-

munity emergency preparedness where local

hospitals partner with state and community agen-

cies to strengthen local responses. Outcomes of

the HPP include benchmark initiatives to improve

responses such as the National Hospital Available

Beds for Emergencies and Disasters (HAvBED)

system which includes a bed-tracking system to

better measure response capabilities (Cantrill

et al., 2005; Sauer, McCarthy, Knebel, & Brewster,

2009). The DHHS is also developing a single

national veri¢cation system that will improve co-

ordination of volunteers resulting from integration

of the Emergency System for Advance Registra-

tion of Volunteer Health Professionals and Medical

Reserve Corps.

Since 2001,The Joint Commission (TJC), the not-for-

pro¢t agency for voluntary accreditation of hospi-

tals, expects the inclusion of comprehensive

emergency management using an all-hazards

approach. For the ¢rst time hospitals were required

Denise Danna, DNS, RN,NEA-BC, FACHE, isassistant professor andassociate dean in the Schoolof Nursing, Louisiana StateUniversity Health SciencesCenter, New Orleans, LA.

Gloria Giarratano, PhD,APRN, CNS, is P.K.Scheerle Professor ofNursing in the School ofNursing, Louisiana StateUniversity Health SciencesCenter, New Orleans, LA.

Robbie Prepas, CNM, MN,JD, is chair of the DisasterPreparedness Committee ofthe American College ofNurse Midwives and anadjunct professor in theSchool of Nursing,University of CaliforniaLos Angeles, NewportBeach, CA.

Cherie Barker Johnson, RN,BSN, is director ofobstetrics at the Woman’sHospital, Baton Rouge, LA.

Emergency preparedness is essential to manage thespecial needs of hospitalized women and newborns in

times of disaster.

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to conduct a hazards vulnerability analysis to prior-

itize and plan responses to incident speci¢c threats

that they were likely to face. Hospitals were required

to set up an incident command system to be used

during an emergency to coordinate the hospital’s

responses from a central location and authority. In

2008 standards were revised to plan for resilience

and assess surge capabilities. Thus hospitals are

expected to plan critical resources for at least 96

hours of self-reliance; have plans for management

of utilities, safety and security, and communication

systems; and prepare sta¡ to focus on teamwork

and collaboration in rapidly changing situations

(Danna, Bernard, Jones, & Mathews, 2009).

The O⁄ce of Public Health Emergency Prepared-

ness and the Agency for Healthcare Research and

Quality (AHRQ) developed a report that outlines

how to deliver services and care in mass casualty

events by analyzing such processes as triage and

providing care with scarce resources (AHRQ,

2005). The American Nurses Association (ANA,

2002a, 2002b, 2008) has developed several reports

in the form of position and policy papers to address

nurses’ roles and responsibilities related to disas-

ters. The ANA’s position statement on Registered

Nurses’ Rights and Responsibilities Related to

Work Release During a Disaster (2002a) provides

guidelines for the registered nurse to use who re-

quests to be excused or released from work to

respond in a disaster. A companion position state-

ment was also written by ANA (2002b) that

addresses the employer and the development of or-

ganizational policies and procedures relating to

the release of registered nurses from work during

a disaster. In 2008 ANA released a policy paper,

Adapting Standards of Care Under Extreme Con-

ditions: Guidance for Professionals During Disas-

ters, Pandemics, and Other Extreme Emergencies,

that addresses the important questions regarding

ethics and standards that apply during extreme

circumstances.

At the international level, the World Health Organi-

zation (WHO) and the International Council of

Nurses (ICN) joined together to develop a set of

core disaster nursing competencies. The ICN

Framework of Disaster Nursing Competencies

(World Health Organization [WHO] and the Inter-

national Council of Nurses [ICN], 2009) provides

the foundation for preparing nurses to functional

e¡ectively in providing disaster relief. The compe-

tencies address the role of the nurse in the phases

of disaster management and serve as a standard

for development of disaster education and training

for nurses around the world. Nursing education

FEDERALPresident

Homeland SecurityNational ResponseFramework (NRF)

STATEGovernor

State HomelandSecurity

EmergencyAgencies

LOCALElected Officials

EmergencyManagement

Fire, Police, PublicWorks, Social Services,

Public Health

HOSPITALAdministrator

Incident CommandDepartment Heads

Nursing ManagementStaff Nurses

Figure 1. Organization of disaster management.

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programs are designing introductory disaster nurs-

ing courses based on the competencies to help

undergraduate students gain the required knowl-

edge and skills to respond to disasters (Pang,

Chan, & Cheng, 2009).

Disaster Management ProcessThe disaster management process includes four

basic phases: mitigation, preparation, response

and recovery (TJC, 2005) and is used to address

all facets related to a disaster. Minor variations in

the labels and number of phases in the disaster

management process may be seen in various

government and agency documents; however TJC

publications re£ect terminology most commonly

used in the National Response Plan (TJC, 2005).

Figure 2 displays the disaster management process

used by hospitals in developing and maintaining a

state of readiness. Each phase of the process is as-

sociated with speci¢c activities along the disaster

continuum. The disaster management process

can create challenges that are complex and over-

whelming where actions in each phase are needed

to minimize or decrease the impact of a disaster

(WHO & ICN, 2009). The process is continuous and

involves using what is learned from one disaster to

assist in preparing for future events.

Mitigation PhaseMitigation includes ‘‘measures taken to reduce

the harmful e¡ects of a disaster by attempting

to limit its impact on human health, community

function, and economic infrastructure’’ (Veevema,

2007, p. 6). The goal is to minimize the impact of a

disaster or, if possible, prevent the disaster. Mitiga-

tion should focus on long-term measures for

minimizing or eliminating structural risks such as

maintaining compliance with safety and building

codes and zoning requirements, ensuring ade-

quate £ood levee protection, installing £ame-

retardant shingles in a ¢re prone area, as well as fo-

cusing on potential nonstructural risks such as

legislation that addresses insurance coverage for

disasters. In a perinatal hospital setting, mitigation

includes identifying additional safe space to which

mothers and infants can be relocated (i.e., away

from windows, lower £oors in case of evacuation)

by nurses who are knowledgeable about this pa-

tient population. Nurses play an active role in the

planning and design of new perinatal units.

Proactive measures during hospital renovation pro-

jects, such as installation of hurricane shutters in a

renovated Neonatal Intensive Care Unit (NICU) with

a large number of windows, can potentially reduce

signi¢cant wind and water damage. Long-term in-

frastructure planning for adequate back-up power

sources to supply electrical needs of obstetrical

settings is also critical for operating rooms for emer-

gency Cesarean deliveries, infant respiratory or

incubator support, and monitoring of laboring high-

risk patients. Alternate water sources should also be

considered in sites prone to extreme £ooding or

earthquakes (Mitchell et al., 2009).

During the mitigation phase hospitals are expected

to perform a hazard vulnerability assessment (HVA).

An HVA is conducted to identify conditions caused

by either physical, cultural, social, or economic fac-

tors that can increase the exposure of a community

to hazards. An HVA involves examining and forecast-

ing the probability and severity of harm, the impact

on the facility and community, and the level of pre-

paredness of the facility to manage the disaster

(TJC, 2005). A prioritization of the hazards identi¢ed

in the HVA assessment will enable the hospital to

make decisions and develop speci¢c goals and ob-

jectives that are in the best interest of the facility. An

agency providing obstetrical services needs to have

an estimate of the number of childbearing women in

the community who may need services. Additionally,

the agency should be aware of the social and eco-

nomic issues that might a¡ect the population and

make themmore vulnerable to health care complica-

tions after a disaster. The mitigation phase is a

continual process, and an analysis of hazards

should be conducted routinely.

Preparedness PhasePreparedness refers to the ‘‘proactive planning

e¡orts to structure the disaster response prior to

Active involvement of perinatal nurses in disastermanagement is essential to minimize risk to women

and newborns.

Figure 2. The disaster management process.

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its occurrence’’ (Veevema, 2007, p. 6). Planning

remains the cornerstone for preparing health care

responders and institutions to anticipate the needs

of the community and plan actions to reduce the im-

pact of disasters on the a¡ected population. Lack of

adequate preparedness can create an environment

of disorganization and anarchy with the potential of

increasing injuries and loss of life (WHO & ICN,

2009). For a hospital, an emergency operations

plan that is straightforward, comprehensive, simple

to implement, and developed in collaboration with

government agencies, emergency responders,

other health care professionals, and community

representatives is an essential component of disas-

ter preparedness (Counts & Prowant, 2001). The

emergency operations plan must address such is-

sues as the chain of command; preparing and

training hospital sta¡; activities to reduce the hospi-

tal’s vulnerability ; securing adequate inventory of

supplies and equipment; promoting community

awareness through collaboration, coordination,

and communication methods; testing the plan by

conducting drills and exercises, and evaluating

drills and exercises to assess the hospital’s pre-

paredness capabilities; thereby identifying areas

for improvement. The hospital’s emergency opera-

tions plan must be coordinated with federal, state,

and local agencies to ensure alignment and com-

pliance. A strong example is the U.S. Department of

Homeland Security’s National Incident Manage-

ment System (NIMS).

Preparedness begins by understanding the com-

munity’s risks and vulnerabilities and initiating

multilevel planning at national, state, and local lev-

els, including the role of health care institutions.

Disaster management focuses on an all-hazards

approach whereby mitigation, preparedness, re-

sponse, and recovery address various types of

potential disastersçenvironmental (i.e., hurricane,

tornado, earthquake), hazardous materials (i.e., ra-

diation, toxic chemicals), terrorism and weapons of

mass destruction (i.e., bombs, chemical agents),

and public health emergencies (i.e., in£uenza pan-

demic, severe acute respiratory syndrome [SARS])

(Lindell & Perry, 2008; TJC, 2005). This all-hazards

approach provides a comprehensive level of pre-

paredness that addresses a full range of emer-

gencies (TJC, 2005) and addresses six critical areas

of emergency management that includes commu-

nication, resources and assets, safety and security,

sta¡ responsibilities, utilities management, and pa-

tient clinical and support activities (TJC, 2007).

Each nurse should begin the disaster preparedness

process by developing a personal disaster plan that

takes into consideration her or his work obligations

that might include reporting to work and remaining

onsite for several days. Each nurse needs to identify

family options for care of dependent family mem-

bers and animals in cases of emergency. Those

institutions who choose to provide shelter for sta¡s’

family members or pets need a plan that considers

the additional resources required to provide for

safety, food, water, and space. Lessons learned

from the Hurricane Katrina disaster indicated ad-

vantages and disadvantages to having family

members shelter within the hospital complex (Ber-

nard & Mathews, 2008). Although evacuation of

family members from the disaster risk area is usually

considered best when natural disasters can be an-

ticipated, a protocol that considers sheltering sta¡’s

family members in cases when disaster strikes with-

out warning may be warranted.

Sta¡ who respond and work in a disaster need

targeted education and training that provides

them with the knowledge, skills, and competencies

to provide quality care to victims in need of services.

Sta¡ education must include, but is not limited

to, the triage process, hospital-speci¢c policies

and procedures relating to care of patients during

a disaster, incident command structure, evacuation

procedures, transportation methods, and the de-

contamination process. Table 1 provides examples

of external sites for continuing education. Emer-

gency management drills and exercises should be

conducted at least twice a year, with one drill focus-

ing on a community-wide exercise (TJC, 2003). The

purposes of conducting emergency management

drills are to train sta¡, identify weaknesses, and

make corrections and improvements to the emer-

gency operations plan (TJC, 2003).

The unit-speci¢c emergency operations plan is ex-

pected to be thoroughly articulated during new hire

orientation and annually thereafter. This would in-

clude information such as the unit’s emergency

sta⁄ng plan and what essential items to bring when

reporting for work during a disaster. Preparations

might include appropriate changes of clothing for

work in harsh conditions (heat or cold) and bringing

one’s own food, water, £ashlights, batteries, and radio.

If the hospital uses a rotating schedule of sta¡ teams

assigned to work either during or after a disaster,

nurses should know the expectations. Sta¡ must be

prepared to be £exible, patient, and self-reliant, keep-

ing themselves nourished and hydrated (Slepski,

2007). Sta¡ must know how changing information will

be disseminated. A clear channel of communication

using websites, e-mail, or hotlines must be planned

for sta¡ to know when and where to report.

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The families of hospitalized women and infants

need to be included in the communication chain.

Written instructions should be developed and

shared with each family on the perinatal units and

contact information for family members should be

updated. Family members should be prepared for

what to expect if they choose to remain with the

hospitalized mother or infant. Resources are avail-

able to assist nurses in developing disaster

preparation teaching tools for families (Giarratano

et al., in press; March of Dimes, 2006). The hospital

needs to collaborate with civil authorities to deve-

lop community public service announcements to

instruct childbearing families on where to seek shel-

ter or evacuate and under what conditions to

access limited hospital services.

Hospital-wide evacuation plans are also a major

component of preparedness planning. Evacuation

planning identi¢es the conditions under which the

facility would evacuate, including deciding on

which patients will be ¢rst to evacuate and who

would receive them. Procedures are needed to dis-

seminate information about evacuation routes and

available shelters to those patients and their fami-

lies being discharged or not requiring medical

care. It is essential that hospitals maintain a log

documenting essential information about patient

evacuation (i.e., evacuation site, time and date

of evacuation).

Surge Capacity PreparednessSurge capacity and triage of patients (admission

and discharge) are two areas of special focus in

hospital preparedness. According to TJC (2003),

de¢ning the hospital’s surge capacity is one of the

most essential parts of an emergency operations

plan. Surge capacity is de¢ned as ‘‘the ability to ex-

pand capabilities in response to sudden or more

prolonged demand’’ (TJC, 2003, p. 19). Hospital

surge capacity refers to the sudden and unex-

pected increase in patients needing services that

would severely challenge the capabilities and re-

sources of the institution (Hick, Barbera, & Kelen,

2009). Disasters have the potential to stress every

aspect of the health care delivery system. Consider

what would happen if the patient admissions dou-

bled over a few hours. This increase in census may

represent surge of patients with multiple needs

crossing over many departments, such as seen in

an in£uenza pandemic or can be limited to speci¢c

needs such as adult or neonatal critical care beds.

Ability to respond to surge is based on the manage-

ment of space, available beds, sta¡ and supplies,

equipment and medications, and legal capacity to

provide care when the hospital’s capacity has ex-

ceeded its limit (TJC). Hospitals should consider all

options in addressing surge capacity potential with

a goal to be self-su⁄cient with ample supplies for at

least 96 hours. Strategies to assist hospitals in be-

coming self-su⁄cient during surge periods include

standardizing equipment, supplies, and medication

doses. Critical supplies for obstetrical and newborn

care such as peripads, blankets, diapers, pediatric

needles, bottles, special formula, and medications

need to be identi¢ed and alternate suppliers

planned. During a disaster, the usual resources for

securing additional incubators, radiant warmers,

Table 1: Disaster Training Resources

The George Washington University

Department of Nursing Education

Nurses on the frontline: Preparing for emergencies and disasters

(Free or CEU)

http://learning.nnepi.org/catalog/

University of Minnesota Emergency

Readiness and Training

Emergency Preparedness for Pregnant/Birthing Women and Newborns/Children

CEU Series:

Caring for Pregnant/Birthing women and their newborns during disasters:

An introduction to the issues

Caring for women giving birth

Caring for postpartum and breastfeeding women

Caring for newborns

http://www.nursing.umn.edu/MERET/MERETModules/home.html

U.S. Dept. of Homeland Security FEMA

Center for Domestic Preparation

NobleTraining Facility Courses: Healthcare Courses

http://cdp.dhs.gov

International Nursing Coalition for Mass

Casualty Education

Nursing Curriculum for Emergency Preparedness

http://webapps.nursing.vanderbilt.edu/incmcemodules2/main.html

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ventilators, and infusion pumps from outside ven-

dors may not be available.

Established agreements with nearby health care fa-

cilities for the purpose of transferring patients or

obtaining additional critical equipment and sup-

plies should be included as part of the hospital

surge capacity plan (TJC, 2006). There should be

prearranged agreements for transport of high-risk

mothers and newborns under speci¢ed conditions.

Clear communication between referral and receiv-

ing hospitals is necessary to determine the level of

patient acuity and equipment needs. All e¡orts

should be made to keep lactatingmothers and their

newborn infants together. For high-risk infants, spe-

cial consideration should be given in planning for

the transport and handling of humanmilk. Hospitals

transferring high-risk neonates to a surge hospital

should plan to bring equipment as well as sta¡ for

each infant. There should be a mechanism to en-

sure proper identi¢cation of each piece of equip-

ment including hospital name and asset number,

whereas the receiving hospital should document

receipt of loaned equipment upon admission of

the infant. This process assists evacuated hospi-

tals in recovering valuable equipment needed for

reopening.

In times of disaster it is common for people to go to a

hospital to seek shelter or safety. This is especially

true for pregnant women who see the hospital as a

safe haven. During a disaster or emergency situa-

tion this would not be the case, however, as room

is needed for women requiring medical interven-

tion. Surge capacity in obstetrical areas mandates

preplanning and evaluating space that can be re-

served for normal labor and births, for complica-

tions of pregnancy, surgery space, and for isolation

of patients for birth and care in case of an in£uenza

outbreak. Large rooms such as recovery rooms,

waiting rooms, clinic space, and conference rooms

can be converted to patient care areas. Elective sur-

geries and inductions are immediately cancelled,

leaving only essential services. Discharge of pa-

tients who are ready or near ready for discharge is

also an important strategy to address surge.Criteria

for early and immediate discharge of patients can

be used to guide decisions. Early discharge of post-

partal women and normal newborns can be carried

out using assessment criteria, assuming there is a

safe place for discharge, such as an appropriate

shelter if home is not an option. Initiation of breast-

feeding would be one key factor in determining

discharge readiness, because bottle feeding may

not be sustainable.

Surge capacity planning is part of the daily routine

in many obstetrical and NICUs. In hospitals with a

busy high-risk antepartum service, delivery of sev-

eral high-risk women with multiple fetuses within a

short period of time can result in a sudden increase

in the labor and delivery and NICU census that may

exceed the normal unit capacity. A proactive

approach is required to secure the necessary

equipment and sta¡ before the expected deliveries,

especially when the unit census is already at ca-

pacity. Obstetrical and neonatal nurse managers

can use a similar on-call system when planning for

an expected increase in unit census following a di-

saster. The same principles used in management of

sudden census spikes can be modi¢ed and applied

to disaster planning.

Surge capacity planning for the high-risk neonatal

population requires critical evaluation of all avail-

able alternate physical spaces outside the NICU.

Patient acuity and level of care determine the phys-

ical environment and equipment needs for each

infant. National design standards specify the mini-

mum number of square feet per bedspace and

requirements for electrical, oxygen, air and vacuum

outlets, as well as evacuation routes and exits in the

NICU (White, 2007). However, few hospitals can

meet these standards when forced to use an alter-

nate location within the main facility. When a

decision is made to shelter in place, it may be nec-

essary to relocate NICU patients to another area of

the hospital. Oxygen, air, and vacuum outlets are

critical needs in an alternate physical space. Post-

anesthesia care units can often be used as an

alternate space for relocating the NICU population

or planning for neonatal admissions from a hospital

under evacuation.

Response Phase

The National Response Plan de¢nes response as

‘‘those activities that address the short-term, direct

e¡ects of an incident. These activities include im-

mediate actions to preserve life, property, and the

environment; meet basic human needs; and main-

tain the social, economic, and political structure of

the a¡ected community’’ (DHS, 2004, pp. 53^54).

The National Response Framework describes

how to implement response activities at all levels of

Perinatal nurses need education and training toapply disaster management principles that guide care

of hospitalized women and newbornsduring extreme conditions.

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government (DHS, 2008). Hospitals are expected to

implement the Hospital Incident Command System

(HICS). HICS is the standard for health care disaster

response and is a response infrastructure under the

NIMS. The HICS provides the organization with a

predictable chain of command, as well as a de¢ned

scope of supervision and job duties, and allows for

£exible and rapid response to events before, during

and after the event. HICS utilizes ¢ve functional ar-

eas (command, operations, planning, logistics, and

¢nance-administration).

It is during this response phase that collaboration

and communication is critical between local, state,

and national levels for an e¡ective disaster re-

sponse to occur. During this phase the urgent

needs of survivors are met. Nurses must have the

necessary knowledge and skills to competently as-

sess, triage, and monitor survivors for physical and

mental health issues, and provide appropriate care

in an environment with limited resources (WHO &

ICN, 2009). Evacuation of the hospital and reloca-

tion of patients, visitors, and sta¡ usually occurs

during the response phase of the disaster. Nurses

should be trained on evacuation procedures such

as developing a process for infallible identi¢cation

of infants, identifying evacuation sites for mothers

and infants, identifying proper evacuation equip-

ment (i.e., vests), and establishing back-up or

alternate evacuation routes (Schultz, Pouletsos, &

Combs, 2008). At one hospital after Hurricane Kat-

rina, well newborn babies and their mothers had to

be evacuated by boats to access ambulances sev-

eral miles away. Family members should be kept

together whenever possible to provide support to

each other. If it becomes necessary to separate

mothers from sick babies or family, there should be

a system in place to assist in reconnecting families

as soon as possible.

Adapted Standards of CareLarge-scale disasters that overwhelm the system

also disrupt the usual standards and expectations

that guide health care delivery. Situations resulting

in scarce equipment and supplies, limited sta¡ and

support services (dietary, laundry, sterilization,

pharmacy), and infrastructure losses (electricity,

water, plumbing, sanitation) will change nursing

care delivery. Priorities shift to providing only essen-

tial care. During the time of disaster, the expected

goal of providing the best, complete nursing care

based on the individualized needs of the patient

may change to a utilitarian framework of care in

which the objective is to provide the greatest good

for the greatest number of individuals. When this

shift is called for by an incident command structure

in the institution, there needs to be guidance on

what conditions of care will change. TJC requires

that hospitals predetermine what routine activities

would be delayed or omitted, such as vital signs,

baths, extensive charting, and nonessential medi-

cations (TJC, 2006).

Perinatal nurses must have the knowledge and £ex-

ibility to change from high-tech to low-tech

management of care, if required. Changes in care

would likely include intrapartal nurses assisting wo-

men to labor without epidural support or minimal

medication if electronic monitoring capabilities are

limited, and depending on maternal warmth for

neonatal temperature stabilization. In most all situa-

tions, breastfeeding would be recommended for

infant feeding. All standards of care in obstetrics

and neonatal nursing need to be considered in the

context of extreme conditions. For example, if con-

tinuous electronic fetal monitoring (EFM) is not

available, what would be the expectations for ma-

ternal/fetal assessment for a woman in normal

labor? At what point might nonlicensed personnel

or family members be used to monitor or provide

basic care for mothers and newborn infants?

Perinatal nursing sta¡ may ¢nd themselves working

in new patient-care situations, requiring rapid train-

ing.This may be likely in surge situations where well

obstetrical and neonatal patients are discharged or

transferred ¢rst, leaving neonatal and obstetrical

nurses to assist with medical-surgical adult pa-

tients or the elderly. What rapid training would be

needed to prepare a neonatal intensive care nurse

to work in an adult critical care site, with no prior

cross training?

In all situations, however, nurses are required to

practice competently to be best of their ability.

Adapting Standards of Care under Extreme Condi-

tions (ANA, 2008) should be used as a guide for

professionals planning care during disasters. Al-

though acknowledging there are challenges, this

ANA paper addresses the professional responsibil-

ity of nurses to adapt standards of care to provide

the best possible care with the resources available.

This includes using their best professional judg-

ment at all times. Nurses who volunteer for out of

state disaster relief work have an obligation to know

the laws governing the practice of nursing in that

state. Contact with the state board of nursing is es-

sential (ANA, 2002a).

Disaster TriageAmong the most challenging issues for nurses is di-

saster triage whereby decisions are made on who

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will receive care based on the likelihood of survival,

commonly referred to as ¢eld triage. Triage is a skill

that combines an assessment of the status and

prognosis of the patient with knowledge of the med-

ical resources available for treatment. Advanced

practice nurses including nurse midwives, clinical

nurse specialists, and nurse practitioners with ex-

pertise in advanced assessment of mothers and

infants can ¢ll critical disaster response roles in tri-

age, transfer, and discharge (Cole, 2005). A shift to

a utilitarian ethical framework necessitates that

scarce resources be used to provide immediate

care for those most likely to recover without ex-

traordinary means. This also includes deciding

which patients have priority for transfer from the di-

saster area to a full-care facility.These decisions are

best made by a designated triage o⁄cer or those

trained to use established criteria or algorithms to

categorize, score, or rank patients based on who

will bene¢t most from immediate emergency care

(Qureshi & Veenema, 2007).

Table 2 lists an example of triage criteria commonly

used in disaster situations. Patients are categorized

based on type and severity of illness or injury, and

assessment of airway, breathing, circulation, vital

signs, level of consciousness, and by visual inspec-

tion. Although nurses working on hospital units may

not be directly involved in the triage process, they

care for patients based on triage decisions, provid-

ing speci¢c interventions to support those who are

likely to recover, and palliative care to those not ex-

pected to survive. Nurses need to understand the

triage decisions made and be prepared to care for

patients in this complex situation, using competen-

cies that support worker and patient safety and the

basics of airway, breathing, circulation, control of

blood loss, and infection control (Gebbie, Peterson,

Subbarao, & White, 2009).

It is essential that the in-patient birth center and

neonatal units develop a triage plan for all mothers

and neonates entering the units for care following a

disaster or during a pandemic. This plan should in-

clude the resources of the obstetrical unit and the

special needs of pregnant women and newborns

(Woodson, 2009). The triage process will serve as

a critical tool to assess the pregnant patients that

present at the obstetrical units and to prioritize their

most immediate concerns. Criteria for prioritizing

obstetrical patients that require hospitalization ver-

sus those who can be discharged home or to

community shelters should be preestablished and

ready for use by sta¡.

Assessment of resources required for essential care

for pregnant women include considering needs of

laboring patients (uncomplicated and previous Ce-

sarean delivery), breech presentations or fetal

distress in labor requiring operative interventions,

prolonged rupture of membranes, multiple births,

diabetics, severe pregnancy induced hypertension

(PIH) and placenta previa or abruption. Availability

of resources is an important element in applying di-

saster-level triage in care of obstetrical patients. For

example, if blood products are scarce, the supply

might be reserved for emergency use in laboring

patients and not released for use on awoman expe-

riencing acute HELLP syndrome, with multiple

health complications.

Resources in the NICU, as well, might be channeled

to the neonates with the greatest chance of survival.

Extremely low-birth-weight neonates in need of

ventilator support would have little chance of sur-

vival without continuous care and resources. The

degree of prematurity may be one consideration in

triage of high-risk neonates. However, full-term ne-

onates may have life-threatening multisystem

medical or surgical conditions that may not be

treatable during a disaster with limited resources.

Education and understanding of disaster triage as

it relates to mothers and high-risk newborns are es-

sential for nurses because decisions and

subsequent actions taken during a disaster may be

considerably di¡erent from care provided under or-

dinary circumstances.

Recovery PhaseThe recovery phase can be considered a short-

term and long-term activity. The National Response

Framework describes recovery as ‘‘the actions ta-

ken to help individuals, communities, and the

Nation return to normal’’ (DHS, 2008, p. 45). After a

disaster, recovery focuses on setting up temporary

housing, providing medical care, supplying the

Table 2: Disaster Triage

Red (emergent) Critical life threatening; Immediate

intervention likely will save lives

Yellow (urgent) Acute problem, illness or injury, stable but

may deteriorate. Requires treatment

within 20 min to 2 hr

Green (nonurgent) Injured or ill but stable; not likely to

deteriorate if treatment delayed up to

2 hr (walking wounded)

Black (expectant) Dead or expected to die; nonsalvageable

with current resources available

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public with current information and health and

safety education, and implementing counseling

programs. Hospitals that reopen postdisaster need

to anticipate women and their newborn infants us-

ing medical emergency services for routine care

due to disrupted clinics and pediatric services in

the community. Mental health clinics may need to

be expanded to address long-term stress in the

community. Hospital-based social services will

need referrals for women who lack housing, food

and infant supplies, or are in need of day care ser-

vices.The long-term goal of the recovery phase is to

restore the a¡ected area to its previous state as

much as possible. This phase involves rebuilding,

reemployment, and repairing the infrastructure. It is

crucial that coordination and collaboration with the

community occurs. During this phase, a postdisas-

ter evaluation should be conducted within the

organization to identify areas for improvement.

ConclusionA series of major disasters in the past 10 years has

highlighted the need for nurses and other health

care workers in hospitals and other health care set-

tings to know and understand their role in the

disaster management process. Nurses have a vital

role in participating in all phases of the disaster pro-

cess at the federal, state, and local level. Hospitals

have an obligation to maintain a state of readiness

for unexpected or expected extreme emergencies.

Optimal hospital emergency planning requires in-

put from expert nurses with knowledge and

experience with speci¢c patient populations such

as new mothers and high-risk infants. Disaster edu-

cation and practice drills are essential for all

hospital care providers. When disaster strikes and

resources are limited, nurses have a duty to provide

care using their skills, knowledge, and best profes-

sional judgment.

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Continuing Nursing Education

To take the test and complete the evaluation, please visit

http://JournalsCNE.awhonn.org.

Certi¢cates of completion will be issued on receipt of the

completed evaluation form, application and processing

fees. Note: Accredited status does not imply endorsement

by AWHONN or ANCC of any commercial products dis-

played or discussed in conjunction with this activity.

Learning Objectives

Upon completion of this article, participants will be able to

1. Explain the role of government agencies in assisting

hospitals during disasters.

2. De¢ne the four phases of the disaster management

process.

3. Give one example of appropriate use of disaster tri-

age principles in the perinatal setting.

4. De¢ne surge capacity.

5. Explain the role of the perinatal nurse when adapted

standards of care are utilized during a disaster.

Test Questions

1. Which of the following is a true statement about

the e¡ects of disaster or pregnant women?

a. Complications such as low birth weight and

prematurity are known to occur following a

disaster.

b. No documented e¡ects have been noted in

women who received prenatal care.

c. The e¡ect of disaster on pregnancy is related

to the location and duration of the event.

2. The recommendations from the 2007 National

Working Group for Women and Infant’s Needs

in Emergencies in the United States provided

a. a guide for disaster management in acute

care and community settings.

b. a higher rate of disaster related reimburse-

ment for pregnant women.

c. the establishment of protocols for emer-

gency shelter of mothers and infants.

3. In the mitigation phase of disaster manage-

ment, the goal is to

a. lessen the impact or potential for damage.

b. plan for evacuation to a surge hospital.

c. repair damage to physical facilities.

4. When local and state governments are over-

whelmed by the impact of a disaster, the

federal response is initiated through the

a. Centers for Disease Control (CDC).

b. Department of Homeland Security (DHS).

c. World Health Organization (WHO).

5. The advanced practice perinatal nurse is best

suited for which of the following disaster man-

agement roles?

a. incident command

b. sta¡ education

c. triage

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6. Current standards require hospitals to plan

critical resources necessary to continue oper-

ating for at least ____ _hours of self-reliance during

and after a disaster.

a. 48

b. 72

c. 96

7. Which of the following statements demon-

strates appropriate use of disaster triage

principles in the neonatal intensive care unit?

a. All available resources will be reserved for

the lowest birth weight infants.

b. E¡orts and resources will be directed to in-

fants with the highest probability of survival.

c. Infants with multisystem organ failure and

life-threatening surgical conditions will be

evacuated ¢rst.

8. Hospitals should perform a hazards vulnera-

bility assessment (HVA) to

a. determine the resources needed for the

most likely disasters in their location.

b. determine what can be done to prevent di-

sasters from occurring.

c. identify surge hospitals for evacuation of

mothers and newborns.

9. The details of a hospital evacuation plan are

developed during which phase of the disaster

management process?

a. mitigation

b. preparedness

c. response

10. Which of the following activities should be

carried out in the recovery phase of disaster

management?

a. Determining the cost of resources

b. Releasing limited information

c. Setting up counseling programs

11. The use of adapted standards of care

during times of disaster requires that the

nurse

a. practice with a prede¢ned scope deter-

mined by the unit manager.

b. provide care only to patients within his/her

area of experience and expertise.

c. use skill, knowledge, and the best decision

making under the di⁄cult circumstances.

12. When disaster nursing care is guided by a util-

itarian framework, the nurse will

a. give the best, complete care for the good of

the individual.

b. provide the greatest good for the greatest

number of individuals.

c. ration care and resources equally among all

in need.

13. Which of the following applies to a labor and

delivery nurse who volunteers for disaster re-

lief work in a neighboring state?

a. No license is required since this is a state of

emergency.

b. The employer is obligated to assist the nurse

in obtaining a temporary permit.

c. The nurse is obligated to know the law of the

state of practice.

14. Responsibilities of a surge hospital providing

care for mothers and newborns include

a. preplan sta⁄ng, supplies, and equipment

for several days of self-su⁄ciency.

b. provide nurses with 24 hours of o¡ duty time

for every 72 hours worked.

c. setting up an isolation area for all admis-

sions from evacuated hospitals.

15. Which of the following obstetric patients would

be classi¢ed as a ‘‘red’’ emergent case need-

ing ¢rst priority for helicopter transfer from a

disaster-disrupted hospital with limited surgi-

cal services to a full-care facility 30 minutes

away?

a. Eighteen-year-old primigravida, dilated

7 cm, in active term labor, breech presenta-

tion, occasional late decelerations.

b. Thirty-year-old, gravida III, para III, 6 hours

postpartum, boggy uterus, moderate bleed-

ing, retained placental fragment suspected.

c. Twenty-eight-year-old, gravid II, para I, 32

weeks gestation, placenta previa, early la-

bor begins, with moderate bleeding.

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